What are the best IV placement sites for infants?

Best IV Placement Sites for Infants

For peripheral IV access in infants, use the upper extremities (hands and forearms) as the primary sites, with the scalp as an acceptable alternative in neonates and young infants, and reserve the lower extremities only when upper sites are unavailable. 1

Preferred Peripheral IV Sites by Age

Neonates and Young Infants

• The scalp veins are acceptable and commonly used sites in neonates and young infants due to their visibility and accessibility 1
• Upper extremity sites (hands and forearms) remain the preferred first choice when accessible 1
• Lower extremity sites should be avoided when possible and replaced with upper extremity access as soon as feasible 1

Older Infants (Beyond Neonatal Period)

• Upper extremity sites are strongly preferred over lower extremity placement 1
• If a lower extremity catheter was placed, it should be replaced to an upper extremity site as soon as possible 1
• The scalp becomes less practical as infants grow and develop more hair 2

Intramuscular Injection Sites (When Needed)

For IM Medications and Vaccines

• The anterolateral thigh (vastus lateralis muscle) is the preferred site for infants and young children receiving intramuscular injections 1
• The deltoid muscle should not be used in infants—it is reserved for older children and adults 1
• Administer at a 90-degree angle to ensure proper intramuscular placement 3

Central Venous Access Considerations

When Peripheral Access is Inadequate

• For infants requiring parenteral nutrition or therapy exceeding 6 days, consider a peripherally inserted central catheter (PICC) or midline catheter rather than repeated peripheral attempts 1
• Avoid femoral vein access when other sites are available due to higher infection risk 1
• For central venous catheters, the catheter tip should be positioned outside the pericardial sac to prevent cardiac tamponade—a life-threatening complication particularly in neonates 1

Special Populations

• In premature infants with posthemorrhagic hydrocephalus requiring long-term IV access, central access devices may be necessary 1
• For infants with conditions requiring frequent IV access (such as osteogenesis imperfecta), port-a-cath placement is safe and efficacious, reducing iatrogenic trauma from repeated access attempts 4

Critical Technical Points

Site Selection Factors

• Nurse experience and competence correlate with successful placement, but time of day, predicted difficulty, and child cooperativeness are better predictors of success 5
• Successful IV placement in children typically requires an average of 2 attempts over 28 minutes 5
• Ultrasound guidance using a real-time, dual operator method may actually decrease success rates compared to conventional technique in children with one failed attempt 6

Monitoring and Maintenance

• Evaluate the catheter insertion site daily by palpation through the dressing to detect tenderness 1
• Remove peripheral catheters if signs of phlebitis develop (warmth, tenderness, erythema, or palpable venous cord) 1
• Routine catheter changes at 72-96 hours are not recommended—only change when clinically indicated 1
• All cannulae must be flushed after use to maintain patency 1

Common Pitfalls to Avoid

• Never use steel needles for administering fluids or medications that could cause tissue necrosis if extravasation occurs 1
• Avoid insertion in limbs with lymphedema except in acute emergencies due to increased infection risk 1
• Do not use peripheral IV access for high osmolality solutions (>500 mOsm/L), extreme pH solutions (<5 or >9), or access needs exceeding 2 weeks 1
• The smallest practical cannula size should be used to minimize vein trauma 1